Provider Demographics
NPI:1952502262
Name:THOMAS NICOLLA PT OF DELMAR
Entity Type:Organization
Organization Name:THOMAS NICOLLA PT OF DELMAR
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:THOMAS
Authorized Official - Middle Name:
Authorized Official - Last Name:NICOLLA
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:518-786-1667
Mailing Address - Street 1:711 TROY SCHENECTADY RD
Mailing Address - Street 2:SUITE 209
Mailing Address - City:LATHAM
Mailing Address - State:NY
Mailing Address - Zip Code:12110-2442
Mailing Address - Country:US
Mailing Address - Phone:518-786-1667
Mailing Address - Fax:518-786-1954
Practice Address - Street 1:10 VISTA BLVD
Practice Address - Street 2:
Practice Address - City:SLINGERLANDS
Practice Address - State:NY
Practice Address - Zip Code:12159-2187
Practice Address - Country:US
Practice Address - Phone:518-478-9049
Practice Address - Fax:518-478-0133
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-05-31
Last Update Date:2017-05-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QP2000XAmbulatory Health Care FacilitiesClinic/CenterPhysical Therapy
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY000413955001OtherBSNENY
NYCH8550OtherRAILROAD MEDICARE
NYAA0454Medicare PIN